This inspection took place on 23 and 24 July 2018. The first day was unannounced, which meant the service did not know we were coming. The second day was by arrangement.

Lightbowne Hall is a 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Lightbowne Hall is a large three storey detached property in Manchester. The home provides residential care for up to 52 people. At the time of the inspection there were 50 people living in the home. The home has large communal areas on each floor with separate dining areas. Each floor also has a quiet lounge. The kitchen and laundry facilities are on the ground floor of the building and there is a hairdresser’s salon on the first floor. All floors are accessible by a lift and stairs.

Our last inspection took place on 27 June 2017 when we rated the service requires improvement. At that inspection we found the provider had implemented a number of positive improvements. However, at this inspection we have found the provider has failed to sustain these improvements and we have identified three new breaches of legal requirements in relation to insufficient staffing levels, care planning and activities, and the quality assurance systems. We requested the provider to tell us in an action plan how they were going to put right the concerns in respect of these breaches.

The manager had been at the service for approximately two months at the time of this inspection. On the second day of inspection the manager confirmed he had received confirmation of his registration with the Care Quality Commission (CQC). Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the home is run.

The service was not staffed safely to meet people's needs. The service was also not staffed in line with the stated provider's minimum staffing levels. As a result, people's basic care needs were not being met. Examples of this included, people not always having their skin integrity needs met and people did not always receive social stimulation within the home, due to a lack of staff.

Staff were observed being kind and compassionate to people throughout the inspection, but their ability to have quality time with people was being compromised by all the tasks they needed to complete.

Demands on staff time meant that staff were not reading people's care plans and risk assessments. Care staff relied on the team leaders to tell them informally and verbal information from other staff. Although care plan records have steadily improved over the last two inspections, essential details were still missing from these, which meant the staff team could not be sure they were using up to date information about people's current needs. Care records were not fully completed which meant people's changing needs could be missed. Monitoring of people's skin integrity repositioning charts were not always completed correctly. This meant people were vulnerable to unsafe and inaccurate care.

People had access to activities, however we received mixed feedback with regards to the activities provided. People were not always protected from social isolation. The range of activities available were not always appropriate or stimulating for people.

We found arrangements in place for the safe management of people's medicines and regular checks were undertaken. People received their medicines as prescribed.

Staff were provided with relevant training to make sure they had the right skills and knowledge for their role. However, staff did not always receive appropriate supervision and regular appraisals in line with the providers policy.

Staff understood what it meant to protect people from abuse. They told us they

This inspection took place on 27 June 2017. This inspection was unannounced, which meant the service did not know in advance we were coming.

Lightbowne Hall is a large three storey detached property in Manchester. The home provides residential care for up to 52 people. At the time of the inspection there were 47 people living in the home. The home has large communal areas on each floor with separate dining areas. Each floor also has a quiet lounge. The kitchen and laundry facilities are on the ground floor of the building and there is a hairdresser's on the first floor. All floors are accessible by a lift and stairs. The service provider had transferred in 2015 from Ideal Care homes to Anchor Care homes.

Our last inspection took place on 14 and 16 November 2016 when we rated the service as inadequate overall and for safe and well led. We rated the effective, caring and responsive domains as requires improvement. As the previous inspection in November 2016 had rated the service as inadequate overall, we placed the service into 'Special Measures' because it was inadequate in two of the five domains.

Following our last inspection we issued two warning notices in relation to breaches of regulations relating to the provision of safe care and treatment and good governance. This meant we sent a formal notice to the provider and registered manager that they must become compliant with the regulations by 06 February 2017 in relation to safe care and treatment and good governance. The provider sent us an action plan to tell us the improvements they would make in order to become compliant with the regulations. At this inspection we found the provider had made significant improvements and they were meeting the requirements of the regulations.

At this inspection we found there had been improvements which were sufficient for the service to be rated as requires improvement overall and good in caring, with no inadequate domains. This meant the service could come out of special measures.

The service had a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We noted improvements in medicines management from the last inspection in November 2016 and some examples of good practice. However, temperatures had not been recorded on three consecutive days in May 2017 and two days in June 2017.

People and care staff told us there were enough staff on duty. The registered manager had used a dependency tool to calculate staffing levels. We observed that people's basic needs were met and the staffing levels at the time our inspection were adequate.

Care assessments and plans had improved since the last inspection and were seen to be detailed and person-centred. However, we identified one person who at times displayed behaviours that may challenge others, that did not have a risk management care plan to help guide staff when supporting them. We found one person living with dementia didn’t have a dementia care plan in place to guide staff about their specific needs.

The involvement of people and their relatives in care planning had improved since our last inspection. Care workers knew people well as individuals and we saw warm and friendly interactions between people and care workers.

We found accident records at the home were comprehensive and evidence showed people were monitored effectively following an accident.

Some senior care staff at the home had received advanced training in end of life care and people had their future wishes recorded in their care plans.

Activities at the home were much improved since our last inspection in November 2016. The area manager held a dementia awareness workshop with staff to share good practice o

This inspection took place over two days on 14 and 16 November 2016. The first day was unannounced, which meant the service did not know in advance we were coming. The second day was by arrangement.

Lightbowne Hall is a large three storey detached property in Manchester. The home provides residential care for up to 52 people. At the time of the inspection there were 50 people living in the home. The home has large communal areas on each floor with separate dining areas. Each floor also has a quiet lounge. The kitchen and laundry facilities are on the ground floor of the building and there is a hairdresser’s on the first floor. All floors are accessible by a lift and stairs. The service provider had transferred in 2015 from Ideal Care homes to Anchor Care homes.

At the comprehensive inspection of Lightbowne Hall on 16 July and 4 August 2015 we identified seven breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (HSCA). We issued the provider with seven requirements stating they must take action to address these breaches. We shared our concerns with the local authority safeguarding team.

Following that inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to these breaches. This inspection was undertaken to check that they had followed their plan, and to confirm that they now met all of the legal requirements.

During this inspection we found that some improvements had been made. However, they were not sufficient enough to meet the requirements of the regulations.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.”

At the time of the inspection, the service had a manager registered with the Care Quality Commission (CQC). A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The registered manager was on annual leave at the time of the inspection. There were arrangements in place to cover the management of the service including an area manager and support from the deputy managers.

People's medicines were not managed safely. For example, we found one person had recently been discharged from hospital w

One inspector carried out this inspection. We met the manager who was in the process of applying for registration with the Care Quality Commission (CQC). We also met the area manager. We talked with four residents and three relatives who were visiting on the day of our inspection. We talked with other staff including two cooks, and we observed care being given. We also looked at care records and other files.

We set out amongst other things to answer five key questions: "Is the service safe? Is the service caring? Is the service responsive? Is the service well-led? Is the service effective?"

The evidence that supports this summary can be found in our full report.

Is the service safe?

We saw that the building was well designed for the needs of people living there and with their safety in mind. There were appropriate arrangements in place to ensure people were kept safe within the building. Outside the building there was an enclosed garden and seating areas for people to enjoy in warm weather.

We found that Lightbowne Hall usually identified any issues related to safeguarding and correctly reported them to the local authority and to the CQC. However, we found there were two recent safeguarding issues which had not been reported as they should have been.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which apply to care homes. We found that one application for an urgent DoLS authorisation had been completed incorrectly. The omission was remedied on the day of our visit. However, we found that this contributed to a finding that the service was not meeting the standard on safeguarding.

Is the service caring?

We spoke with four people who all said they felt well looked after. One person said: "The staff here are friendly. They have been very good to me." When we spoke with staff and the manager it was clear they genuinely cared for the people they supported. The service was person centred and took into account the diverse range of people needing support. We found the home respected people's preferences, interests and wishes, and cared about the people using the service. We saw that the home was providing physical exercise for those people who wanted to participate. We thought that there could be a wider range of activities provided.

Is the service responsive?

The service responded to people's needs by providing an appropriate level of care. The manager had tried to involve relatives in reviews of care plans, and was seeking ways to do so more effectively. The service had responded positively to two areas of non-compliance identified in our last inspection.

Is the service effective?

We saw that people were well-cared for, so the service was effectively fulfilling its main purpose. The visitors we met stated that they were very satisfied with how their family members were being looked after. We found that care plans were thorough and based on a good system.

Is the service well-led?

The manager was experienced and was in the process of applying to become registered manager. They were supported by the area manager who made regular visits and was present on the day of our inspection. There was a deputy manager and senior carers, and staff understood the chain of responsibility. The emphasis of the service was on ensuring people received good care and were treated with dignity and respect.

We spoke with eight people who used the service on the day of our inspection. We spoke to fourteen visitors to the home. Most were relatives in groups and who visited five people who used the service.

We were told: “All the carers are very polite and they don’t rush me. You need time to do things at my age and they let me go at my own pace”. And: “The carers make you feel at home as well as the residents”.

We found no evidence that people who used the service or their relatives had been involved in the planning or reviews of their care and treatment. None of the people we spoke with could recall having been involved in consenting to their care.

Relatives we spoke with told us that they had probably given appropriate consent to the care and treatment for their relative, but none could recall having been involved in a review of their relatives care plan.

We found that people’s care and welfare needs were met by the service and healthcare professional were regularly consulted.

People told us they felt safe. Staff had been trained in protecting vulnerable people and the service had systems in place to respond to any allegations of abuse.

We found that there were insufficient numbers of staff on duty to respond in a timely manner to people’s needs for care and welfare.

The home had a complaints system in place although there was room for improvement in terms of bringing minor complaints to the attention of the manager.

This was the first inspection of Lightbowne Hall since it was registered with us in March 2012. There were 50 people living at Lightbowne Hall on the day of our inspection. The premises were new and purpose built.

We saw people living at Lightbowne Hall being treated with dignity and respect. We spoke with a selection of people who use the service, the manager, staff, relatives and professionals who had visited the service. Some people we spoke with were living with dementia and not all people were able to fully share with us their views with us.

One person told us "I am very happy here". Another person said "It is very good here” We saw that people expressed their views and were involved in making decisions. One person told us "They do ask me how I want things to be done".

Prior to our visit we had been made aware of concerns about the management of medication. We checked to see if there continued to be problems and found no areas of concern.

We looked at the recruitment of staff, and found the service had undertaken robust checks to make sure staff they employed were suitable to work with people using the service.

People we spoke with said that they felt there were not always enough staff on duty. Although at the time of our inspection we saw no evidence of this.

Staff told us that they liked working at the home and were supported in their work. We saw that processes had been in place to monitor the overall quality of the service provided.

We carried out an inspection of this service on 16 July and 4 August 2015. The inspection was unannounced on both days. This means the service did not know when we would be undertaking the inspection.

At the last inspection in May 2014 the provider was found non-compliant with one regulation as they had not informed the CQC of two safeguarding notifications. The provider sent CQC an action plan to say how they would meet the regulation. We used the action plan provided to ascertain if the work had been completed and found that it had been.

Lightbowne Hall is a large three storey detached property in Manchester. The home provides residential care for up to 52 people. At the time of the inspection there were 50 people living in the home. The home has large communal areas on each floor with separate dining areas. Each floor also had a quiet lounge which was rarely used at the time of inspection. The kitchen and laundry facilities were on the ground floor of the building and there was a hairdresser’s on the first floor. All floors were accessible by a lift and stairs.

The home had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have a legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

We found systems designed to detect and investigate potential abuse were in place and staff were confident in using them.

Over the two days of the inspection we found there was not enough staff to meet people’s needs. We saw people waiting for unacceptable lengths of time to be supported. We saw medicines were administered late due to staffing issues and people waited for up to four hours from waking before receiving anything to eat. We therefore found the home was in breach of the regulation relating to staffing.

We reviewed people’s care files and found where risks had been identified they were not always managed to support the person at risk. We found the home did not have suitable procedures in place to support people in the event of an emergency. This included the lack of an available contingency plan to ensure the service could be continued in the event the building could not be used. We also found individual plans to support people in an emergency had not been reviewed since people became resident at the home. We also found that they did not include enough information about how to mobilise people if they needed to be evacuated from the building. We found the home were in breach of the regulation relating to safety as they had not taken appropriate steps to ensure people would always be kept safe.

We found staff were recruited safely. Suitable checks were made to ensure people recruited were of good character and had appropriate experience and qualifications.

Whilst reviewing how the home managed and administered medicines we found a number of concerns. These included people receiving their medicines late and in ways which were not appropriately assessed. Medicines were given covertly (hidden) without an assessment to determine if doing this was in the person’s best interest. We also found systems and processes were ineffective to ensure people’s medicines did not run out or used within their best by date. We also found the management of topical medicines, including creams to be applied, were not effective. Records showed some people were not receiving their topical medicines and some other medicines as prescribed. We found the home in breach of the regulation relating to management and administering medicines. Procedures were not in place to ensure medicines were administered safely and when medicines were given covertly the correct process was not followed in line with the Mental Capacity Act 2005.

When walking around the building we noted whilst communal areas were mostly clean and tidy, people’s bedrooms and ensuites were not. Flooring in clinical rooms was sticky and flooring was not sealed allowing for build-up of grime and potential bacteria. We found these rooms were not always locked creating an increased risk of people gaining access to clinical areas. We found the home was in breach of the regulation relating to the building was managed it had not kept areas clean and secure increasing the risk of infection and cross contamination.

We reviewed the information and support available to ensure people received enough nutrition and hydration. We found records were not held as required to support people at risk of not receiving enough nutrition and hydration. We found advice given by specialist teams including GPs and dieticians was not always followed. Records kept to monitor people’s intake of food and fluids were poorly completed and did not accurately record what people had consumed. We found the home was in breach of the regulation relating to nutrition and hydration as people were not sufficiently supported to ensure their nutritional intake was adequate.

The home had comprehensive documents for gaining people’s consent. However these were not completed in the files we looked in. People we spoke with assured us they were always asked for their consent.

Staff we spoke with told us the training they received was good but supervision and appraisals had been limited. However we did see records to indicate many people had received supervision. Team meetings had been less formal with a limited number of minutes being available. Staff told us that different staff groups got together to discuss areas that were relevant to them as a team.

We were told by visiting professionals, and we saw within records held at the home, that they worked with relevant professionals to meet people’s needs. We saw referrals made to supporting teams relevant to people’s needs. We were also told staff were very busy and visiting professionals would be better supported if staff had more time to engage with them.

The people who lived in the home and their visitors and relatives were all positive about the staff. We were told they were very nice and looked after people as best they could.

We saw staff interacting with people in positive and caring ways but it was clear that at times they were simply too busy and some interactions were rushed or missed. We heard staff talk about different people’s care needs in communal areas and saw private and personal information left open on dining room tables where visitors and other people in the home had access. We found the home in breach of the regulation in relation to people’s privacy as we did not find this was always respected.

We noted within people’s files that information regarding people’s use of glasses, hearing aids and dentures was prominent in their files and staff were prompted to ensure people had these items at all times.

We spoke with people about how they spent their days. We were told by most people there was not enough to do. The manager told us activities were the responsibility of the care staff.

Within the care plans we reviewed we noted a number of concerns with how pressure care was delivered within the home. We saw assessments and reviews were not always completed and used to develop and deliver the most appropriate care. We saw people’s needs were not met and support was not monitored effectively to reduce risks. We found the home was in breach of the regulation in relation to safe care as assessments and reviews were not meeting people’s needs.

We saw a complaints procedure was available within the home on notice boards and in the resident information pack. People we spoke with were confident they knew how to make a complaint and those people we spoke with that had made a complaint were happy with how it had been managed.

Audits on the home’s quality were not accurate which meant systems to improve the quality of provision at the home was not effective. Cleaning schedules were completed in advance leaving the schedule’s purpose ineffective. We found the home in breach of the regulation in relation to good governance as there were not effective systems in place to monitor the quality of the service.

We found accident records at the home were comprehensive and evidence showed people were monitored effectively following an accident.

The kitchen and laundry were organised with appropriate risk assessment and cleaning schedules.

Surveys were completed but the information was not collated and used to improve provision at the home..

We have asked the proved to take action to meet the regulations. You can see the action we have asked the provider to take at the back of this report.